Transcript Title text….

Acute Stroke Management Resource:
Neurological Assessment
2007
Neurological Assessment: Objectives
To present the rationale for a focused
neurological assessment
 To present the components of a two minute
neurological assessment
 To present the components of a focused
neurological assessment
 To review three assessment scales used in
stroke
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Focused Neurological Assessment
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History
 Stroke onset, risk factors and symptoms
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General Medical Assessment
 Associated conditions, etiology, additional investigations
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Neurological Examination
 Localizes the lesion, exclusion of other symptoms
 Rules out stroke mimics
 Suggests provisional diagnosis
 Determines additional investigations
 Determines management care plan
Localization
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Hemisphere
 Anterior circulation
 Posterior circulation
 Cerebellum
Brain Stem
 Spinal Cord
 Peripheral Neuropathy
 Muscle
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History
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History
 Time of symptom onset
Accurate time of symptom onset is critical
o Obtain from patient or person present when the patient was
last seen normal
o
 Associated features
o
Seizure, loss of consciousness
General Medical Assessment
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ABC: airway, breathing, circulation
Blood Pressure
 tPA candidates: <185/110mmHg
 Non tPA candidates: 220/120mmHg
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Pulse: irregularity may indicate atrial fibrillation
Temperature: >37.5°C is an independent predictor of
poor outcome
Blood glucose: hyperglycemia associated with worse
stroke outcomes
General system screen
2 Minute Neurological Examination
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Assess:
 Pupils, fundi, visual fields, extraocular movements
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Ask patient to:
 Show me your teeth, say “ah” and stick out your tongue
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Assess:
 Facial sensation
 Muscle tone and strength
 Sensory function
 Reflexes
 Coordination
Neurological Assessment
Level of consciousness
 Screening for aphasia
 Cranial Nerve assessment
 Motor function
 Coordination and gait
 Reflexes
 Sensory function
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Level of Consciousness
Most ischemic stroke patients are conscious
 Assessment of level of consciousness
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 Ask the patient:
What month is it?
o How old are you?
o
 Response to commands:
Ask patient to open and close their fist
o Ask patient to open and close their eyes
o
Screening for Aphasia
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Aphasia: loss of ability to use written and oral language
25% of stroke survivors
50% of individuals with left hemisphere strokes
Bedside screening includes:
 Comprehension
 Expression & naming
 Repetition
 Reading
 Dysarthria
Cranial Nerves Funduscopic Examination:
Optic (II)
Identify disk,
sharpness of margins
www.heartandstroke.ca/profed
Examine macular
area for anterior
lesions
Follow vessels
emerging from disk
Cranial Nerves Visual Fields: Optic (II)
www.heartandstroke.ca/profed
Cranial Nerves Pupillary Response:
Optic (ll) and Oculomotor (lll)
Assess size prior to light
 Elevation of eyelid
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www.heartandstroke.ca/profed
Cranial Nerves: Extraocular Movements
Oculomotor (III), Trochlear (IV), Abducens
(VI)
www.heartandstroke.ca/profed
Cranial Nerves
Facial Sensation: Trigeminal (V)
www.heartandstroke.ca/profed
Cranial Nerves
Facial Strength: Facial (VII)
Smile, show your teeth,
lift your eyebrows
www.heartandstroke.ca/profed
Cranial Nerves Palate and Tongue:
Glossopharyngeal (IX),Vagus (X)
Ask patient to say “ah”
www.heartandstroke.ca/profed
Motor Function Tone and Strength
Ask patient to close
eyes, arms extended
with palms upward
www.heartandstroke.ca/profed
Neurological Assessment: Coordination and
Gait
Finger-Nose-Finger test
www.heartandstroke.ca/profed
Heel-to-shin test
Neurological Assessment: Reflexes
Deep tendon reflex exam
www.heartandstroke.ca/profed
Plantar reflex exam
Stroke Scales:
National Institute of Health Stroke Scale
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Measures
 11 items
 Physiological deficits
 Does not measure activity, ADL or participation abilities
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Scoring
 Quantitative, weighted to severity
 0-42, higher score indicative of greater neurological deficits
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Characteristics
 Reflects comprehensive neurological exam
 Results correlate with presenting symptoms
 Primarily suited to acute care
 Accurate, reliable and well validated
 Training required to ensure accuracy in use
Stroke Scales:
Canadian Neurological Scale
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Measures
 6 items
 Impairment or physiological deficit
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Scoring
 0-11.5, lower score indicative of greater neurological deficit
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Characteristics
 Reflects common areas related to stroke presentation
 Primarily used in acute care
 Used in conjunction with Glasgow Coma Scale
 Accurate, reliable, sensitive to change, predictive of death,
reinfarction and functional independence at 6 months
 Training resources available from HSFO
Stroke Scales:
Glasgow Coma Scale (GCS)
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Measures
 3 items
 Level of consciousness or coma
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Scoring
 3-15 with lower score indicative of greater neurological deficit
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Characteristics
 Developed as a standardized and valid tool for assessing level of
consciousness
 Not felt to be sensitive enough for stroke patients who do not
have impaired level of consciousness
 Used in conjunction with CNS if level of consciousness is impaired
Conclusions
Rapid assessment and triage key to optimal
treatment
 CT scan required to exclude hemorrhage
 Knowledge of typical stroke symptoms key
 Anatomical and etiological diagnosis necessary
 Exclusion of stroke mimics vital
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Resources
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American Association of Neuroscience Nurses
www.aann.org
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American Stroke Association
www.strokeassociation.org
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Brain Attack Coalition
www.stroke-site.org
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Canadian Hypertension Education Program
www.hypertension.ca/chep/en/default.asp
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Canadian Stroke Strategy
www.canadianstrokestrategy.ca
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European Stroke Initiative
www.eusi-stroke.com
Resources
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Heart and Stroke Foundation Prof Ed
www.heartandstroke.ca/profed
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Heart and Stroke Foundation of Canada
www.heartandstroke.ca
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Internet Stroke Centre
www.strokecenter.org
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National Institute of Neurological Disorders and Stroke
www.ninds.nih.gov
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National Stroke Association
www.stroke.org/site/PageServer?pagename=HOME
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Scottish Intercollegiate Guidelines Network
www.sign.ac.uk
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StrokeEngine
www.medicine.mcgill.ca/strokengine